Emergency Surgery: 5% of Patients Readmitted

Diedtra Henderson

November 12, 2015

About 1 in 20 patients who undergo emergency general surgery (EGS) find themselves back in a hospital within 30 days, according to a study published online November 11 in JAMA Surgery. In addition, patients with high comorbidity scores were 2.26 times more likely to be readmitted than those with low scores, and one in five readmitted patients went to a different hospital for readmission.

"Higher readmission rates were seen in patients 65 years and older (10.59%), black patients (11.01%), and patients with high Charlson Comorbidity Index scores (17.11%) compared with other patients," write Joaquim M. Havens, MD, from the Division of Trauma, Burn, and Surgical Critical Care and Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues.

"Among patients younger than 65 years, the major reason for readmission was surgical infections (20.47%) followed by gastrointestinal illnesses (11.67%). For patients 65 years and older, 10.40% were readmitted owing to gastrointestinal illnesses, and 9.27% of readmissions were owing to surgical infections."

According to Dr Havens and colleagues, nearly half of all patients who undergo EGS will have a postoperative complication, which may leave them at higher risk for readmission. To identify risk factors associated with readmission, the researchers analyzed California State Inpatient Database records from 2007 to 2011 and included 177,511 adult patients in their review. Some 57.07% were white, 48.76% were privately insured, 51.26% were at least 45 years old, and 72.63% were hospitalized for fewer than 4 days. The five most common EGS procedures (laparoscopic cholecystectomy, laparoscopic appendectomy, other incision with drainage of skin and subcutaneous tissue, other appendectomy, and other partial resection of the small intestine) made up more than 50% of operative procedures performed on patients, the authors write.

"We found that EGS patients who were on public insurance, had higher comorbidity status, had longer lengths of hospital stay, and had discharge dispositions other than home were more likely to be readmitted within 30 days," the research team notes. Such factors "serve as markers for high-risk patients in whom more aggressive approaches to management are needed."

In an accompanying invited commentary, O. Joe Hines, MD, from the Department of Surgery, David Geffen School of Medicine at the University of California at Los Angeles, writes that "the opportunity for surgeons and hospitals to prevent readmission lies first with instituting systemwide bundled interventions to prevent [surgical site infections]." Such preventive measures, Dr Hines says, include "appropriate antibiotics before incision, chlorhexidine washes before surgery, normothermia and euglycemia intraoperatively, clean instrument trays for closing, and patient education, [and] require the buy-in across services and disciplines."

Although the study authors worried about care fragmenting because one in five patients was readmitted to a different hospital, Dr Hines writes that electronic health records and the "creation of large health systems" will help ensure that the 15% to 20% of patients who are not readmitted to the index facility that performed their EGS receive better care.

Dr Havens and colleagues conclude that "it is critical to understand the underlying factors associated with readmission to appropriately identify quality-improvement measures that address the true problem. Focused and concerted efforts should be made to incorporate readmission-reducing strategies into the care of EGS patients, particularly among those at higher risk for readmission."

One study author disclosed being cofounder of and an equity shareholder in Doctella. The remaining study authors and the commentator have disclosed no relevant financial relationships.

JAMA Surg. Published online November 11, 2015. Article full text, Commentary extract


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